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Claes D, Markham KB, Cortezzo DE. An Ethical Analysis of Therapy for Severe Congenital Kidney and Urinary Tract Anomalies. Pediatrics 2024; 153:e2023064720. [PMID: 38784992 DOI: 10.1542/peds.2023-064720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 05/25/2024] Open
Abstract
Technological advancements before and after delivery have greatly altered the counseling of pregnant patients facing a fetal diagnosis of severe oligohydramnios or anhydramnios secondary to congenital anomalies of the kidneys and urinary tract. Once considered a nearly uniformly lethal abnormality, long-term survival may now be possible secondary to prenatal innovations aimed at restoring the amniotic fluid volume and the availability of more advanced neonatal dialysis techniques. However, these available therapies are far from perfect. The procedures are onerous for pregnant patients without a guarantee of success, and families must prepare themselves for the complex life-long medical care that will be necessary for surviving individuals. Multidisciplinary counseling is imperative to help pregnant individuals understand the complexity of these conditions and assist them in exercising their right to informed decision-making. Moreover, as with any developing field of medicine, providers must contend with ethical questions related to the treatment options, including questions regarding patient-hood, distributive justice, and the blurred lines between research, innovation, and standard care. These ethical questions are best addressed in a multidisciplinary fashion with consideration of multiple points of view from various subspecialties. Only by seeing the entirety of the picture can we hope to best counsel patients about these highly complex situations and help navigate the most appropriate care path.
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Affiliation(s)
- Donna Claes
- Divisions of Nephrology
- Departments of Pediatrics
| | - Kara B Markham
- Cincinnati Children's Fetal Care Center
- Obstetrics and Gynecology and Division of Maternal Fetal Medicine
| | - DonnaMaria E Cortezzo
- Cincinnati Children's Fetal Care Center
- Neonatal and Pulmonary Biology
- Pain and Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Departments of Pediatrics
- Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Divisions of Neonatology
- Pain and Palliative Care
- Fetal Care Program, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut
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2
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Premkumar A, Fry JT, Bolden JR, Grobman WA, Michelson KN. The value and limitations of using predetermined criteria in decision making for maternal-fetal interventions. Prenat Diagn 2023; 43:792-797. [PMID: 37139690 DOI: 10.1002/pd.6363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/06/2023] [Accepted: 04/26/2023] [Indexed: 05/05/2023]
Abstract
Maternal-fetal interventions-such as prenatal fetal myelomeningocele (MMC) repair-are at the forefront of clinical innovation within maternal-fetal medicine, pediatric surgery, and neonatology. Many centers determine eligibility for innovative procedures using pre-determined inclusion and exclusion criteria based on seminal studies, for example, the "Management of Myelomeningocele Study" for prenatal MMC repair. What if a person's clinical presentation does not conform to predetermined criteria for maternal-fetal intervention? Does changing criteria on a case-by-case basis (i.e., ad hoc) constitute an innovation in practice and flexible personalized care or transgression of commonly held standards with potential negative consequences? We outline principle-based, bioethically justified answers to these questions using fetal MMC repair as an example. We pay special attention to the historical origins of inclusion and exclusion criteria, risks and benefits to the pregnant person and the fetus, and team dynamics. We include recommendations for maternal-fetal centers facing these questions.
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Affiliation(s)
- Ashish Premkumar
- Department of Obstetrics and Gynecology, Pritzker School of Medicine, The University of Chicago, Chicago, Illinois, USA
- Department of Anthropology, The Graduate School, Northwestern University, Evanston, Illinois, USA
| | - Jessica T Fry
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Janelle R Bolden
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Kelly N Michelson
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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3
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Lyerly AD. 'Experimental pregnancy' revisited. THEORETICAL MEDICINE AND BIOETHICS 2022; 43:253-266. [PMID: 35859087 PMCID: PMC9299403 DOI: 10.1007/s11017-022-09578-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 06/15/2023]
Abstract
In this paper, I reflect on an important article by Bob Veatch in the inaugural issue of the Hastings Center Report, entitled "Experimental Pregnancy." It is a report and elegant analysis of the Goldzieher Study, in which nearly 400 women were randomized to receive hormonal contraception or placebo absent consent or disclosure about placebo use, resulting in several pregnancies. Noting the study's limited notoriety, I first consider the narratives that have instead dominated bioethics' approach to pregnancy and research: thalidomide and diethylstibesterol (DES). These narratives have facilitated a narrow focus on avoiding fetal risk, to the exclusion of other ethically relevant considerations. I then revisit "Experimental Pregnancy" and offer two ways in which Bob's analysis serves as an important corrective, first, by foregrounding research subjects (persons who are or may become pregnant), and second, by normalizing pregnancy and thus foregrounding foundational ethical considerations that are sometimes lost amidst pregnancy's presumed exceptionalism.
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Lyerly AD, Verite A, Marshall MF. Restrictions on Abortion, Social Justice and the Ethics of Research in Maternal-Fetal Therapy Trials. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:78-81. [PMID: 35258420 DOI: 10.1080/15265161.2022.2030588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
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5
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Fry J, Premkumar A. What Lies Beneath the Framework: The Importance of Grounding Ethical Discussions of Maternal-Fetal Therapy. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:73-75. [PMID: 38410994 DOI: 10.1080/15265161.2022.2027563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Affiliation(s)
- Jessica Fry
- Northwestern University Feinberg School of Medicine
- Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Ashish Premkumar
- Northwestern University Feinberg School of Medicine
- John H. Stroger, Jr. Hospital of Cook County
- Northwestern University Graduate School
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6
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Ethics experts and fetal patients: a proposal for modesty. BMC Med Ethics 2021; 22:161. [PMID: 34861862 PMCID: PMC8642991 DOI: 10.1186/s12910-021-00730-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/23/2021] [Indexed: 11/22/2022] Open
Abstract
Background Ethics consultation is recognized as an opportunity to share responsibility for difficult decisions in prenatal medicine, where moral intuitions are often unable to lead to a settled decision. It remains unclear, however, if the general standards of ethics consultation are applicable to the very particular setting of pregnancy. Main text We sought to analyze the special nature of disagreements, conflicts and value uncertainties in prenatal medicine as well as the ways in which an ethics consultation service (ECS) could possibly respond to them and illustrated our results with a case example. Ethics facilitation and conflict mediation, currently, have no broadly consented normative framework encompassing prenatal diagnosis and therapy as well as reproductive choice to draw on. Even so, they can still be helpful instruments for ethically challenging decision-making in prenatal medicine provided two additional rules are respected: For the time being, ECSs should (a) refrain from issuing content-heavy recommendations in prenatal medicine and (b) should not initiate conflict mediations that would involve the pregnant woman or couple as a conflict party. Conclusion It seems to be vital that ethics consultants as well as health care professionals acknowledge the current limitations and pitfalls of ethics consultation in prenatal medicine and together engage in the advancement of standards for this particularly complex setting.
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Begović D. Maternal-Fetal Surgery: Does Recognising Fetal Patienthood Pose a Threat to Pregnant Women's Autonomy? HEALTH CARE ANALYSIS 2021; 29:301-318. [PMID: 34674098 PMCID: PMC8529227 DOI: 10.1007/s10728-021-00440-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/24/2022]
Abstract
Maternal–fetal surgery (MFS) encompasses a range of innovative procedures aiming to treat fetal illnesses and anomalies during pregnancy. Their development and gradual introduction into healthcare raise important ethical issues concerning respect for pregnant women’s bodily integrity and autonomy. This paper asks what kind of ethical framework should be employed to best regulate the practice of MFS without eroding the hard-won rights of pregnant women. I examine some existing models conceptualising the relationship between a pregnant woman and the fetus to determine what kind of framework is the most adequate for MFS, and conclude that an ecosystem or maternal–fetal dyad model is best suited for upholding women’s autonomy. However, I suggest that an appropriate framework needs to incorporate some notion of fetal patienthood, albeit a very limited one, in order to be consistent with the views of healthcare providers and their pregnant patients. I argue that such an ethical framework is both theoretically sound and fundamentally respectful of women’s autonomy, and is thus best suited to protect women from coercion or undue paternalism when deciding whether to undergo MFS.
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Affiliation(s)
- Dunja Begović
- Centre for Social Ethics and Policy, The University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, England.
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8
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Schmitz D, Henn W. The fetus in the age of the genome. Hum Genet 2021; 141:1017-1026. [PMID: 34426855 PMCID: PMC9160108 DOI: 10.1007/s00439-021-02348-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 08/16/2021] [Indexed: 12/15/2022]
Abstract
Due to a number of recent achievements, the field of prenatal medicine is now on the verge of a profound transformation into prenatal genomic medicine. This transformation is expected to not only substantially expand the spectrum of prenatal diagnostic and screening possibilities, but finally also to advance fetal care and the prenatal management of certain fetal diseases and malformations. It will come along with new and profound challenges for the normative framework and clinical care pathways in prenatal (and reproductive) medicine. To adequately address the potential ethically challenging aspects without discarding the obvious benefits, several agents are required to engage in different debates. The permissibility of the sequencing of the whole fetal exome or genome will have to be examined from a philosophical and legal point of view, in particular with regard to conflicts with potential rights of future children. A second requirement is a societal debate on the question of priority setting and justice in relation to prenatal genomic testing. Third, a professional-ethical debate and positioning on the goal of prenatal genomic testing and a consequential re-structuring of clinical care pathways seems to be important. In all these efforts, it might be helpful to envisage the unborn rather not as a fetus, not as a separate moral subject and a second "patient", but in its unique physical connection with the pregnant woman, and to accept the moral quandaries implicitly given in this situation.
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Affiliation(s)
- Dagmar Schmitz
- Institute for History, Theory and Ethics in Medicine, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany.
| | - Wolfram Henn
- Institute of Human Genetics, Saarland University, Homburg/Saar, Germany
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9
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Crombag N, Sacco A, Stocks B, De Vloo P, van der Merwe J, Gallagher K, David A, Marlow N, Deprest J. 'We did everything we could'- a qualitative study exploring the acceptability of maternal-fetal surgery for spina bifida to parents. Prenat Diagn 2021; 41:910-921. [PMID: 34228835 PMCID: PMC7613560 DOI: 10.1002/pd.5996] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/05/2021] [Accepted: 06/05/2021] [Indexed: 11/22/2022]
Abstract
Objective To explore the concepts and strategies parents employ when considering maternal-fetal surgery (MFS) as an option for the management of spina bifida (SB) in their fetus, and how this determines the acceptability of the intervention. Methods A two-centre interview study enrolling parents whose fetuses with SB were eligible for MFS. To assess differences in acceptability, parents opting for MFS (n = 24) were interviewed at three different moments in time: prior to the intervention, directly after the intervention and 3-6 months after birth. Parents opting for termination of pregnancy (n = 5) were interviewed only once. Themes were identified and organised in line with the framework of acceptability. Results To parents opting for MFS, the intervention was perceived as an opportunity that needed to be taken. Feelings of parental responsibility drove them to do anything in their power to improve their future child’s situation. Expectations seemed to be realistic yet were driven by hope for the best outcome. None expressed decisional regret at any stage, despite substantial impact and, at times, disappointing outcomes. For the small group of participants, who decided to opt for termination of pregnancy (TOP), MFS was not perceived as an intervention that substantially could improve the quality of their future child’s life. Conclusion Prospective parents opting for MFS were driven by their feelings of parental responsibility. They recognise the fetus as their future child and value information and care focusing on optimising the child’s future health. In the small group of parents opting for TOP, MFS was felt to offer insufficient certainty of substantial improvement in quality of life and the perceived severe impact of SB drove their decision to end the pregnancy.
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Affiliation(s)
- Neeltje Crombag
- Department of Development and Regeneration Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Elizabeth Garrett Anderson Institute of Women's Health, University College London, London, UK
| | - Adalina Sacco
- Elizabeth Garrett Anderson Institute of Women's Health, University College London, London, UK
| | | | - Philippe De Vloo
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Katie Gallagher
- Elizabeth Garrett Anderson Institute of Women's Health, University College London, London, UK.,National Institutes for Health, University College London Hospitals Biomedical Research Centre, London, UK
| | - Anna David
- Department of Development and Regeneration Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Elizabeth Garrett Anderson Institute of Women's Health, University College London, London, UK.,National Institutes for Health, University College London Hospitals Biomedical Research Centre, London, UK
| | - Neil Marlow
- Elizabeth Garrett Anderson Institute of Women's Health, University College London, London, UK.,National Institutes for Health, University College London Hospitals Biomedical Research Centre, London, UK
| | - Jan Deprest
- Department of Development and Regeneration Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Elizabeth Garrett Anderson Institute of Women's Health, University College London, London, UK.,Department of Obstetrics and Gynecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
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10
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Lin TY, Wataganara T, Shaw SW. From non-invasive to invasive fetal therapy: A comprehensive review and current update. Taiwan J Obstet Gynecol 2021; 60:595-601. [PMID: 34247794 DOI: 10.1016/j.tjog.2021.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/16/2022] Open
Abstract
"Fetus as patient" indicates fundamental concept of fetal therapy. With advance in maternal serum analysis and fetal imaging, prenatal screening has become standard of care. Accurate diagnosis in early gestation allows intervention to reverse pathophysiology and delay progression immediately. Non-invasive, minimally invasive and invasive therapies demonstrate their therapeutic potential in certain diseases. Recently, stem cell and gene therapies have been developed to avoid irreversible impairment. To elevate efficacy of treatment modality, extensive studies should be conducted according to regulatory authority. Striking a balance between scientific and ethical integrity is essential, so long-term follow up should be arranged for protecting mother and fetus.
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Affiliation(s)
- Tzu-Yi Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tuangsit Wataganara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Steven W Shaw
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan; Prenatal Cell and Gene Therapy Group, Institute for Women's Health University College London, London, United Kingdom.
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11
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Mason K. Postpartum Maternal Tethering: A Bioethics of Early Motherhood. INTERNATIONAL JOURNAL OF FEMINIST APPROACHES TO BIOETHICS 2021; 14:49-72. [PMID: 35991863 PMCID: PMC9390069 DOI: 10.3138/ijfab-14.1.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This article proposes a new way of conceptualizing the ethical relationship between postpartum mothers and their newborn babies. I suggest that the intertwinement of mother and baby - and the tensions that this intertwinement produces - do not disappear with birth, but rather persist throughout the postpartum period in the form of postpartum maternal tethering. I draw upon three years of ethnographic fieldwork and training in the US and China to argue that the dependency associated with postpartum maternal tethering makes it extremely difficult for postpartum mothers to act autonomously, even in the relational sense. I then examine how breaches in the postpartum maternal tether can open up new possibilities for thinking about the bioethics of vulnerability, dependency and care, by denaturalizing and de-sanctifying the mother-baby relationship and diversifying newborn care.
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Affiliation(s)
- Katherine Mason
- Vartan Gregorian Assistant Professor of Anthropology, Brown University, Box 1921, 128 Hope St., Providence, RI 02912
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12
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Lin TY, Sung CA, Shaw SW. The Application of Clinical Ultrasound in Fetal Therapy. J Med Ultrasound 2020; 29:1-2. [PMID: 34084708 PMCID: PMC8081109 DOI: 10.4103/jmu.jmu_134_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Tzu-Yi Lin
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Ai Sung
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Steven W Shaw
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan.,Department of Prenatal Cell and Gene Therapy, Institute for Women's Health, University College London, London, UK
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13
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Romanis EC, Begović D, Brazier MR, Mullock AK. Reviewing the womb. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106160. [PMID: 32727855 PMCID: PMC8639904 DOI: 10.1136/medethics-2020-106160] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 05/20/2023]
Abstract
Throughout most of human history women have been defined by their biological role in reproduction, seen first and foremost as gestators, which has led to the reproductive system being subjected to outside interference. The womb was perceived as dangerous and an object which husbands, doctors and the state had a legitimate interest in controlling. In this article, we consider how notions of conflict surrounding the womb have endured over time. We demonstrate how concerns seemingly generated by the invisibility of reproduction and the inaccessibility of the womb have translated into similar arguments for controlling women, as technology increases the accessibility of the female body and the womb. Developments in reproductive medicine, from in vitro fertilisation (IVF) to surrogacy, have enabled women and men who would otherwise have been childless to become parents. Uterus transplants and 'artificial wombs' could provide additional alternatives to natural gestation. An era of 'womb technology' dawns. Some argue that such technology providing an alternative to 'natural' gestation could be a source of liberation for female persons because reproduction will no longer be something necessarily confined to the female body. 'Womb technology', however, also has the potential to exacerbate the labelling of the female body as a source of danger and an 'imperfect' site of gestation, thus replaying rudimentary and regressive arguments about controlling female behaviour. We argue that pernicious narratives about control, conflict and the womb must be addressed in the face of these technological developments.
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Affiliation(s)
- Elizabeth Chloe Romanis
- Centre for Social Ethics and Policy, Department of Law, University of Manchester, Manchester, UK
| | - Dunja Begović
- Centre for Social Ethics and Policy, Department of Law, University of Manchester, Manchester, UK
| | - Margot R Brazier
- Centre for Social Ethics and Policy, Department of Law, University of Manchester, Manchester, UK
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14
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Horner C, Burcher P. A surrogate's secrets are(n't) safe with me: patient confidentiality in the care of a gestational surrogate. JOURNAL OF MEDICAL ETHICS 2018; 47:medethics-2017-104518. [PMID: 29899014 DOI: 10.1136/medethics-2017-104518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 04/30/2018] [Accepted: 05/24/2018] [Indexed: 06/08/2023]
Abstract
Gestational surrogacy relies on a legal agreement between the surrogate and the intended parents to define the roles and responsibilities of the parties, including explicit consent by the surrogate to allow the physician to release all pregnancy-related medical information to the intended parents. In the event of surrogate misconduct, however, physicians may feel conflicted if the surrogate asks the physician to withhold information about potentially dangerous behaviour in pregnancy from the intended parents. While the American Society for Reproductive Medicine guidelines may support disclosure over the objections of the surrogate, the authors argue that such disclosure is a violation of the surrogate's rights and the physician's ethical and professional duties. A surrogate's confidentiality must be maintained as it is an essential element of the physician-patient relationship.
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Affiliation(s)
- Claire Horner
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
| | - Paul Burcher
- Department of Obstetrics and Gynecology, WellSpan York Hospital, York, Pennsylvania, USA
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15
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Fry JT, Frader JE. "We want to do everything": how parents represent their experiences with maternal-fetal surgery online. J Perinatol 2018; 38:226-232. [PMID: 29317765 DOI: 10.1038/s41372-017-0040-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/04/2017] [Accepted: 12/12/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE There is little available evidence on how patients make decisions regarding maternal-fetal surgery. We studied online patient narratives for insight on how pregnant women and their partners consider such decisions. STUDY DESIGN We used Google search strings and a purposive snowball method to locate patient blogs. We analyzed blog entries using qualitative methods to identify author details, medical information, and common themes. RESULTS We located 32 blogs of patients who describe maternal-fetal surgery consultation. Twenty-eight (88%) underwent fetal interventions. Most (91%) explicitly described consultation with maternal-fetal surgery teams; 83% of those depicted making decisions prior to formal consultation. Few expressed regret for decisions made (6%). CONCLUSIONS AND RELEVANCE Patients openly share experiences with maternal-fetal surgery online. Women portray their decisions as made outside of formal medical processes and overwhelmingly feel these decisions were "right". As the field of maternal-fetal surgery expands, prospective evaluation of patient decision-making is needed.
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Affiliation(s)
- Jessica T Fry
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Joel E Frader
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Palliative Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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16
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Abstract
This article explores some of the complex ethical challenges that exist in the field of fetal diagnosis and treatment, especially surrounding maternal-fetal surgery. The rise of these new treatments force us to reconsider who or what is the fetus, what are our obligations to the fetus, and what are the limits to those obligations. In addition, we will consider provider and professional biases, disability issues, and how maternal-fetal surgery has, for a select group of women, changed the very experience of motherhood.
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Affiliation(s)
- Ryan M Antiel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Dr, FL 14 Market St, Suite 320, Philadelphia, PA 19104.
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18
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Janvier A, Farlow B. The ethics of neonatal research: An ethicist's and a parents' perspective. Semin Fetal Neonatal Med 2015; 20:436-41. [PMID: 26497942 DOI: 10.1016/j.siny.2015.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The ethics of neonatal research are complex because vulnerable new parents are asked to provide consent on behalf of their fragile baby. Whereas clinical neonatal care has evolved to value personalized and shared decision-making, the goal of research ethics is still to standardize the informed consent process and make it as complete and thorough as possible. Ethicists, lawyers and physicians have shaped the field of research ethics and consent for research. The goal of detailed informed consent is to protect participants from harm, but procedures were developed without input from the principal stakeholders: ex-neonatal intensive care unit parents/patients. Empirical investigations examining patient and parental perspectives on research and research ethics are lacking. Rigorous investigations are needed to determine how parents of sick neonates want their families to be protected, knowing that a lack of research is also harmful. Large randomized controlled multicenter trials will always be needed to improve neonatal outcomes. These trials are costly and time-consuming. Currently, the way in which research is funded and regulated and the way in which academic merit is recognized lead to inefficiency and a waste of precious resources. Following a review of the history of research ethics, this article examines and discusses the ethics of research in neonatology. In addition, challenges and opportunities are identified and ideas for future investigations are proposed.
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Affiliation(s)
- Annie Janvier
- Department of Pediatrics and Clinical Ethics, University of Montreal, Montreal, Canada; Sainte-Justine Hospital Research Center, Montreal, Quebec, Canada.
| | - Barbara Farlow
- The DeVeber Institute for Bioethics and Social Research, North York, Ontario, Canada; Patients for Patient Safety Canada, Canadian Patient Safety Institute, Canada
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Edvardsson K, Small R, Lalos A, Persson M, Mogren I. Ultrasound's 'window on the womb' brings ethical challenges for balancing maternal and fetal health interests: obstetricians' experiences in Australia. BMC Med Ethics 2015; 16:31. [PMID: 25953252 PMCID: PMC4429903 DOI: 10.1186/s12910-015-0023-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 04/24/2015] [Indexed: 11/24/2022] Open
Abstract
Background Obstetric ultrasound has become a significant tool in obstetric practice, however, it has been argued that its increasing use may have adverse implications for women’s reproductive freedom. This study aimed to explore Australian obstetricians’ experiences and views of the use of obstetric ultrasound both in relation to clinical management of complicated pregnancy, and in situations where maternal and fetal health interests conflict. Methods A qualitative study was undertaken as part of the CROss-Country Ultrasound Study (CROCUS). Interviews were held in November 2012 with 14 obstetricians working in obstetric care in Victoria, Australia. Data were analysed using qualitative content analysis. Results One overall theme emerged from the analyses: The ethical challenge of balancing maternal and fetal health interests, built on four categories: First, Encountering maternal altruism’ described how pregnant women’s often ‘altruistic’ position in relation to the health and wellbeing of the fetus could create ethical challenges in obstetric management, particularly with an increasing imbalance between fetal benefits and maternal harms. Second, ‘Facing shifting attitudes due to visualisation and medico-technical advances’ illuminated views that ultrasound and other advances in care have contributed to a shift in what weight to give maternal versus fetal welfare, with increasing attention directed to the fetus. Third, ‘Guiding expectant parents in decision-making’ described the difficult task of facilitating informed decision-making in situations where maternal and fetal health interests were not aligned, or in situations characterised by uncertainty. Fourth, ‘Separating private from professional views’ illuminated divergent views on when the fetus can be regarded as a person. The narratives indicated that the fetus acquired more consideration in decision-making the further the gestation progressed. However, there was universal agreement that obstetricians could never act on fetal grounds without the pregnant woman’s consent. Conclusions This study suggests that medico-technical advances such as ultrasound have set the scene for increasing ethical dilemmas in obstetric practice. The obstetricians interviewed had experienced a shift in previously accepted views about what weight to give maternal versus fetal welfare. As fetal diagnostics and treatment continue to advance, how best to protect pregnant women’s right to autonomy requires careful consideration and further investigation.
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Affiliation(s)
- Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden. .,Judith Lumley Centre, La Trobe University, Melbourne, Vic, 3000, Australia.
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, Vic, 3000, Australia.
| | - Ann Lalos
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden.
| | | | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden.
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Brown SD, Donelan K, Martins Y, Sayeed SA, Mitchell C, Buchmiller TL, Burmeister K, Ecker JL. Does professional orientation predict ethical sensitivities? Attitudes of paediatric and obstetric specialists toward fetuses, pregnant women and pregnancy termination. JOURNAL OF MEDICAL ETHICS 2014; 40:117-122. [PMID: 23572566 DOI: 10.1136/medethics-2012-101126] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND To determine (1) whether fetal care paediatric (FCP) and maternal-fetal medicine (MFM) specialists harbour differing attitudes about pregnancy termination for congenital fetal conditions, their perceived responsibilities to pregnant women and fetuses, and the fetus as a patient and (2) whether self-perceived primary responsibilities to fetuses and women and views about the fetus as a patient are associated with attitudes about clinical care. METHODS Mail survey of 434 MFM and FCP specialists (response rates 60.9% and 54.2%, respectively). RESULTS MFMs were more likely than FCPs to disagree with these statements (all p values<0.005): (1) 'the presence of a fetal abnormality is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-78.4% vs 63.5%); (2) 'the effects that a child born with disabilities might have on marital and family relationships is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-80.5% vs 70.2%); and (3) 'the cost of healthcare for the future child is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-73.5% vs 55.9%). 65% MFMs versus 47% FCPs disagreed that their professional responsibility is to focus primarily on fetal well-being (p<0.01). Specialists did not differ regarding the fetus as a separate patient. Responses about self-perceived responsibility to focus on fetal well-being were associated with clinical practice attitudes. CONCLUSIONS Independent of demographic and sociopolitical characteristics, FCPs and MFMs possess divergent ethical sensitivities regarding pregnancy termination, pregnant women and fetuses, which may influence clinical care.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, , Boston, Massachusetts, USA
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Jones HE, Chisolm MS, Jansson LM, Terplan M. Naltrexone in the treatment of opioid-dependent pregnant women: the case for a considered and measured approach to research. Addiction 2013; 108:233-47. [PMID: 22471668 DOI: 10.1111/j.1360-0443.2012.03811.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The present paper considers naltrexone to treat opioid dependence during pregnancy. The public health problem of opioid dependence and its treatment during pregnancy is reviewed first. Next, the naltrexone and opioid dependence treatment literature is summarized, with overviews of the pre-clinical and clinical research on prenatal naltrexone exposure. Finally, considerations and recommendations for future medication research for the treatment of opioid dependence in pregnant women are provided. The efficacy of long-acting injectable naltrexone relative to placebo, its blockade of opioid agonist euphoric effects, its lack of abuse and tolerance development and its modest adverse effect profile make it a potential medication for opioid-dependent pregnant women. However, it is not without seriously concerning potential drawbacks, including the difficulty surrounding medication induction that may lead to vulnerability with regard to relapse, physical dependence re-establishment, increased risk behaviors, treatment dropout and resulting opioid overdose. Before embarking on future research with this medication, the benefits and risks for the mother-embryo/fetus/child dyad should be weighed carefully. Should future research be conducted, a multi-level commitment to proactive ethical research is needed to reach the ultimate goal of improving the lives of women and children affected by opioid dependence.
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Abstract
Although recent advances have helped identify cases where foetal cardiac surgery might reverse the development of certain lesions, the indications and measurement of success in these procedures have yet to be established. Thus, both patients and physicians have a "burden of knowledge", whereby a diagnosis is made without a clear course of action. The profound issues raised by foetal intervention, specifically the question of how concepts such as "patient" and "success" can be used, complicate this burden further and test the limits of language and logic. Similar issues raised in postmodern philosophy are discussed and can be incorporated into foetal cardiac surgery dialogues to produce a multi-disciplinary approach that will elucidate, not obfuscate, these issues in the future.
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Buchbinder M, Timmermans S. Newborn screening and maternal diagnosis: rethinking family benefit. Soc Sci Med 2011; 73:1014-8. [PMID: 21835525 DOI: 10.1016/j.socscimed.2011.06.062] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2011] [Revised: 06/29/2011] [Accepted: 06/29/2011] [Indexed: 11/26/2022]
Abstract
In a significant departure from established criteria for population screening, a 2006 report by the American College of Medical Geneticists (ACMG) argued that newborn screening may be justified by family and societal benefits even if the screened infant does not stand to benefit. The ACMG report has since been the backdrop for considerable debate about the presumptive benefits of newborn screening. Understandings of family benefits have focused on how information provided by newborn screening may enhance reproductive decision-making, reduce the diagnostic odyssey, and alleviate the burden of raising a child with special health care needs. This paper identifies and describes an additional consequence of newborn screening for families. Specifically, we draw upon audio-recordings and clinical observations from a three-year ethnographic study of expanded newborn screening in California (November 2007-July 2010) to examine the potential for newborn screening to diagnose mothers with genetic disorders. This consequence of expanded newborn screening suggests the possibility of a different type of family spillover from that anticipated by the ACMG report. However, whether this knowledge benefits families depends on how the significance of genetic information is established in the clinic and the family's ability to act on this information. We show that the newborn screening health care infrastructure is not designed to provide treatment for adult patients, so the identification of maternal disease does not necessarily prove beneficial for families.
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Affiliation(s)
- Mara Buchbinder
- University of North Carolina - Chapel Hill, Department of Social Medicine, 333 South Columbia Street, MacNider Hall, Room #348, Chapel Hill, NC 27599-7240, United States.
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Lyerly AD, Little MO, Faden RR. Reframing the framework: toward fair inclusion of pregnant women as participants in research. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2011; 11:50-52. [PMID: 21534152 DOI: 10.1080/15265161.2011.560353] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Anne Drapkin Lyerly
- Center for Bioethics, University of North Carolina at Chapel Hill, 333 South Columbia Street, Chapel Hill, NC 27599-7240, USA.
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Rosenthal MS. The Suleman Octuplet Case: An Analysis of Multiple Ethical Issues. Womens Health Issues 2010; 20:260-5. [DOI: 10.1016/j.whi.2010.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 04/06/2010] [Accepted: 04/06/2010] [Indexed: 11/25/2022]
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